Pathologists reset criteria for worrisome acid reflux disease

A national group of gastrointestinal pathologists have set new criteria for determining when effects of acid reflux disease are likely to develop into cancer of the esophagus, says Marie Robert, associate professor of pathology at Yale School of Medicine who founded the group and participated in the study.

The new criteria are published in a recent issue of the journal Human Pathology, along with a second article that tracked the patients who were diagnosed to see if the pathologists were correct in their assessments.

'A small but significant percentage of people who have chronic gastroesophageal reflux disease will develop inflammation in the lining of the esophagus, and that over time leads to changes referred to as Barrett's esophagus,' said Robert. 'People with Barrett's esophagus are predisposed to develop cancer at that site.'

Patients with Barrett's esophagus are monitored regularly with biopsies for telltale cellular changes. The pathologists examining biopsies from these at-risk patients are on the lookout for pre-malignant changes in cells. 'If these changes are caught early, they can take out the affected portion of the esophagus before it becomes cancerous. Once cancer develops, it's hard to treat and control,' Robert said. 'However, those of us in the field have long recognized that pathologists have a hard time agreeing with each other on how to grade the pre-malignant changes in these biopsies.'

Because accurate diagnosis is so critical to the patient's health and future, pathologists from Yale, Johns Hopkins University, the University of Washington, the Cleveland Clinic Foundation, the University of Michigan, MCP Hahnemann University in Philadelphia, Massachusetts General Hospital, Harvard Medical School, the University of Alabama, Medical University of South Carolina, the University of Chicago, the University of Arkansas, and Vanderbilt University joined together to develop better criteria for determining worrisome changes in patients with Barrett's esophagus. The lead author of the article is Elizabeth Montgomery from Johns Hopkins University.

They submitted slides showing cellular changes, or dysplasia, at five stages: no dysplasia, indefinite dysplasia, low-grade dysplasia, high-grade dysplasia and cancer. They divided the 250 slides into two groups. All 12 pathologists looked at each of the first 125 slides twice without knowledge of the prior diagnosis or discussion of diagnostic criteria. Variation in diagnoses was measured and revised criteria were developed at a consensus meeting. The pathologists then looked at the second batch of 125 slides and found that their agreement improved in several important categories using the new criteria.

A follow up of patients whose biopsies were examined in the study showed that those characterized as having no dysplasia showed no evidence of cancer 48 months later. Those determined to have indefinite or low-grade dysplasia had an 18 percent incidence of developing cancer within a 65-month period. Sixty percent of patients who were diagnosed with high-grade dysplasia developed cancer within seven months.